RESPIRATORY PROTECTION GUIDANCE

1 1 OSHA is committed to protecting the health and safety of America s workers. This GUIDANCE is designed specifically for nursing homes, assisted living, and other long-term care facilities (LTCFs) ( , skilled nursing facilities, inpatient hospice, conva-lescent homes, and group homes with nursing care). LTCFs are different than other healthcare settings because they assist resi-dents and clients with tasks of daily living in addition to providing skilled nursing care. While this GUIDANCE focuses on protecting workers from occupational exposure to SARS-CoV-2 (the virus that causes COVID-19 disease) by the use of respirators, primary reliance on engineering and administrative controls for controlling exposure is consistent with good industrial hygiene practice and with OSHA s traditional adherence to a hierarchy of controls.

2 1 Under this hierarchy, engineering and administrative controls are preferred to personal protective equipment (PPE). Therefore, employers should always reassess their engineering controls ( , ventilation) and administrative controls ( , hand hygiene, physical distancing, cleaning/disinfection of surfaces ) to identify any changes they can make to avoid over-reliance on respirators and other PPE (see CDC s COVID-19 webpage on Nursing Homes and Long-Term Care Facilities). This is especially vital considering the current supply chain demand for N95 filtering facepiece 1 More information about the hierarchy of controls can be found at: PROTECTION GUIDANCE for the Employers of Those Working in Nursing Homes, Assisted Living, and Other Long-Term Care Facilities During the COVID-19 Pandemic2respirators (FFRs). Additional control strategies for preventing exposure to SARS-CoV-2 in LTCFs can be found in OSHA s COVID-19 GUIDANCE for Nursing Home and Long-Term Care Facility Workers and CDC s Nursing Homes and Long-Term Care Facilities.

3 Even when control strategies are in place, PPE, including respirators, will be needed for workers when close contact with someone who is known or suspected of having COVID-19 cannot be avoided. Whenever respirators are required, employers must implement a written, worksite-specific RESPIRATORY PROTECTION program (RPP), including medical evaluation, fit testing,2 training, and other elements, as specified in OSHA s RESPIRATORY PROTECTION standard (29 CFR ). OSHA requirements for other PPE ( , eye PROTECTION , protective clothing) can be found in OSHA s General PPE standard (29 CFR ) and Eye and Face PROTECTION standard (29 CFR ).Face Coverings, Facemasks Authorized for Use as Source Control by the FDA, FDA-cleared or Authorized Surgical Masks, and RespiratorsThere are multiple products/devices that can be used during the COVID-19 pandemic to cover a wearer s mouth and nose, and it is important to select the right one for the situation.

4 These products/devices can provide source control, and some of them are also considered PPE that will protect the wearer as well. Source control refers to the use of a product/device to cover a person s mouth and nose to reduce the spread of RESPIRATORY secretions and aerosols when that person is breathing, talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are currently recommended for everyone in healthcare facilities, including in LTCFs, even if they do not have symptoms of COVID-19. Healthcare providers should wear source control products/devices at all times while they are in a LTCF, including in breakrooms or other spaces where they might encounter other people, including co-workers. The source control product/device should be appropriate for the anticipated exposure(s).

5 These products/devices include: Cloth Face Coverings: These are homemade or commercially available products made of cloth that cover the nose and mouth. Cloth face coverings should NOT be worn instead of an FDA-cleared or authorized surgical mask if PROTECTION against exposure to splashes and sprays of infectious material from others is needed. Cloth face coverings do not provide effective RESPIRATORY PROTECTION for workers 2 Note: In its March 14, 2020, memo ( PROTECTION -annual-fit), OSHA has articulated a temporary policy under which OSHA will exercise enforcement discretion with respect to the annual fit testing requirements in paragraph (f)(2) of 29 CFR for FFRs used in healthcare, as long as the employer conducts initial fit tests for each healthcare professional with the same model, style, and size respirator that the worker will be required to wear for PROTECTION against SARS-CoV-2.

6 Initial fit testing is essential to determine if the respirator properly fits the worker and is capable of providing the expected level of PROTECTION . 3when PROTECTION against airborne hazards is needed, and do not fall under OSHA s RESPIRATORY PROTECTION standard. They are not considered PPE for the wearer, but can assist in source control. LTCF patients and visitors should wear their own cloth face covering upon arrival at and throughout their stay in a LTCF for source If they do not have a cloth face covering, they should be offered a facemask, surgical mask, or cloth face covering by the LTCF, as supplies allow. Facemasks: These products look similar to, and are often mistaken for, surgical masks, but do not provide fluid resistance. They do not provide effective RESPIRATORY PROTECTION for workers when protec-tion against airborne hazards is needed, and do not fall under OSHA s RESPIRATORY PROTECTION standard.

7 They are not considered PPE for the wearer, but can assist in source control. The FDA has authorized the emergency use of facemasks, including cloth face coverings, that meet certain criteria for use as source control by the general public and healthcare personnel in accordance with CDC recommenda-tions during the COVID-19 public health emergency. An example of this type of product would be a KN95 respirator with ear loops instead of head straps and that has not undergone rigorous fit testing to demonstrate a proper fit/effective seal to the wearer s face. FDA-cleared or authorized surgical masks: Surgical masks are cleared, or are authorized for emergency use, by the FDA and are jointly regulated by OSHA under the PPE standard (29 CFR ) and the Bloodborne Pathogens standard (29 CFR ). When available, FDA-cleared or autho-rized surgical masks are preferred over cloth face coverings for healthcare workers, as they offer both source control and PROTECTION for the wearer against exposure to splashes and sprays of infectious material from others.

8 They are loose-fitting devices that do not provide effective RESPIRATORY PROTECTION for workers when the wearer might be exposed to airborne hazards, and do not fall under OSHA s RESPIRATORY PROTECTION standard. Respirators (including FDA-cleared or authorized surgical N95 FFRs): Healthcare providers who are in close contact with an LTCF resident with suspected or confirmed SARS-CoV-2 infection must use a NIOSH-approved N95 FFR or equivalent or higher-level respirator (29 CFR ). When PROTECTION against exposure to splashes and sprays of infectious material from others is also needed, an FDA-cleared or authorized surgical N95 FFR must be worn by healthcare workers (29 CFR and 29 CFR ). Surgical N95 respirators provide the same level of RESPIRATORY PROTECTION as a N95 respirator ; however, a surgical N95 respirator meets the FDA requirements for fluid penetration, flammability, and biocompatibility (see 21 CFR (b)(1)).

9 OSHA regulates respirators under the RESPIRATORY PROTECTION standard (29 CFR ). In order for 3 CDC s most up-to-date recommendations for the general public (vs. healthcare workers) on how to select, wear, and clean a face covering can be found at ).N95 respirators and surgical masks4a respirator to provide the expected level of PROTECTION , it must be used in the context of a RESPIRATORY PROTECTION program (29 CFR ).For additional information see CDC s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) PROTECTION Program (RPP)Employers can refer to OSHA s Small Entity Compliance Guide for the RESPIRATORY PROTECTION Standard for a better understanding of OSHA s RESPIRATORY PROTECTION standard. The guide includes step-by-step instruc-tions for compliance with the standard, checklists, and commonly-asked questions, as well as a sample written RPP.

10 The key elements of an RPP that employers must implement when any of their staff are required to wear respirators include the following: Assign a suitably trained program administrator to oversee all elements of the RPP. This can be an infection prevention and control practitioner or a nurse administrator. If there are no staff members suitably trained to be the program administrator, consider hiring a local industrial hygiene consulting service to help establish a RPP or contact OSHA s On-Site Consultation Implement and maintain a written RPP that details worksite-specific procedures and elements for required respirator use ( , medical evaluation, fit testing, training, maintenance, etc.). Certain program elements may also be required by OSHA for voluntary respirator use in order to prevent potential hazards associated with the use of a respirator .